News and updates from the Penn public health community, by the Center for Public Health Initaitives (CPHI)

Another one of our stellar MPH students, Jasmine Jones, is interning at a non-governmental organization in Botswana focusing on HIV/AIDS advocacy and support for youth and vulnerable populations. Check out her travel blog here!

Check out the Travel Blog of our amazing MPH/MSN student, Joshua Littlejohn. He is working in Mozambique with Y-Center, a social innovation company that operates in Mozambique and India, for 12 weeks during the summer of 2015. The larger project that he is a part of is called Connect The Dots and is an SMS text-based system for disease reporting and supply inventory designed to connect community health workers (CHWs) with the central Ministry of Health. Josh’s project will be to work with the CHWs and local resources to create new visual media for use in education campaigns. These materials should be low-cost, easily reproducible, low-tech, and locally relevant.

He just uploaded his 2nd post: Map to Nowhere

First, I’ll give the basic run down of my week and then we’ll talk about some of the more existential stuff, that’s the fun part anyway. My week is pretty structured for not having a formal schedule or anything. Since I can’t sleep with all this friggin sunlight (hey, I’ve almost only ever worked night shifts, even before I was a nurse) I get up between 6 something and 7 something every morning, even without an alarm clock. My bucket bath in the morning is a great eye-opener and by the time I’m done with that I *almost* don’t need coffee… almost…

This week was the first actual week of work since Dr. Arlindo (the director of CoH) was back from Maputo (the capital) and the three missionaries were in the office. Actually, I think only two of them, Rose and Elfie, are missionaries and the third woman, Pastor Marcia, is local and works for Dr. Arlindo. Elfie is a nurse and Rose did a degree in health sciences and management. They are with the Methodist Church and Rose does the accounting and such for projects while Elfie works on developing the health projects that CoH conducts.

They get here between 7:30 and 8:30 and we have a small breakfast together usually. I’ve most likely had two cups of coffee by that point. Dhairya and I take our stuff into the work room down the hall on the work-side of CoH and make camp for the day at the collection of tables down there. I’ve been working on prototypes of the materials and gathering information about the area, thinking about the realities of life here, and how best to integrate what little information I have collected so far into some sort of meaningful messages.

UNISAF Y Center Banner. The inside of the University. It is basically a giant O shape/square

Maria, who works at CoH in a general-help kind of position, usually puts out a small lunch of bread and cheese, tea, and maybe some boiled eggs. We eat together and chat a bit, then back to work and maybe a meeting with either Dr. Arlindo or the public health team (PHT – Elfie, Rose, and Pastor Marcia) The official work day ends about 3:00 and they actually kick us out of the work-side of CoH so that Manuel (Maria’s counterpart) can lock everything up. Sometimes he’s a bit over zealous and locks things up like the silverware … or dishes… lol.

I’m most likely not done doing whatever it was that I was working on, so I move back to my room and use the desk in there to work some more. I’ve thoroughly spread myself out over the entire room and used every surface that I could. In fact, I’d probably go crazy if there was another person in here with me to share the space… it’s been a long time since those undergrad years when I actually had to share a *room* with someone (not just an apartment).

Check out Penn WIC’s new blog post about Dr. Rosemary Frasso’s Qualitative Methods graduate course for Social work and Public Health Students!

Dr. Rosemary Frasso, Allison Golinkoff (TA) and graduate student research team – Qualitative Research Methods for Social Work (SW 781)

Research seldom happens in silos. Be it through the literature review, data collection, or publication, group collaboration is the ingredient that brings new ideas and perspectives to the research process. It is with this spirit that Dr. Rosemary Frasso (Rosie), Allison Golinkoff (TA), and the student researchers of the Qualitative Methods graduate course for Social Work and Public Health students took teamwork to new heights this spring in theVan Pelt Collaborative Classroom.

From the start, the student researchers employed qualitative methods (Nominal Group Technique) to collectively determine the research topic of “fear and safety” at Penn. Next, each individual student-researcher conducted 5 intercept Freelisting interviews across campus to explore the topic. Using the full 360 degrees of writable whiteboard surfaces in the Collaborative Classroom, students began the process of analyzing Freelisting data to identify salient themes.

Inspired by the work of Drs. Carolyn Cannuscio,Mariana Chilton, and Gala True, Rosie designed this class project employing Photo Elicitation interviewing. Students later made use of this same technique to further explore the meaning of fear and safety across the Penn community. As a team, the class selected a sampling strategy and each student-researcher was tasked with recruiting a participant from within the Penn community to explore how she/he perceives fear and safety. Over the course of one week, research participants used their smartphones or cameras to take photographs of any aspects of their daily lives that made them think of fear or safety. The photos were then used to guide an interview between the researcher and the participant about those topics.

Dr. Frasso turned to group collaboration in the Collaborative Classroom as a strategy to help the student researchers make sense of the sizable amount of data they all collected. Through collaborative analysis, student researchers found that their participants’ views on fear and safety revolved around eight thematic categories: vulnerability; sense of belonging; fear of failure; surveillance; physical and mental health; fear of the unknown; sources of comfort; and spaces and places.

The student researchers of Dr. Frasso’s class see their research findings as a potential catalyst for change at Penn. To this end, they have made their work visible in many ways. You can view their research exhibit, complete with photos and participant quotes, just outside the Van Pelt Collaborative Classroom (right before the WIC entrance, to the right). Students also plan to share their findings with key members of the Penn community such as President Amy Gutmann, CAPS, and GAPSA.

On Sunday, May 3, 2015, Kelsey Sheak, a 2015 Master of Public Health Candidate at the University of Pennsylvania, woke up and prepared to run the 10K Broad Street Run. Shortly after starting the race, she noticed a crowd gathering around a collapsed man. Upon arriving at his side, Kelsey immediately put her CPR training into action. Kelsey was one of the many bystanders who helped this fallen runner survive from his cardiac arrest. Read her full story below.

Kelsey Sheak, 2015 MPH Candidate

CPHI: We heard you performed a life-saving procedure at the Broad Street Run on Sunday, May 3, 2015.

Kelsey Sheak: I did! I was running and between miles 2 and 3 I saw a crowd of people. There was a gentleman in the center of the crowd and he was clearly having a medical emergency. Shortly after I arrived, he lost his pulse. Once he lost his pulse, a group of bystanders and I started administering cardiopulmonary resuscitation (CPR). We communally performed CPR – one person would start, another person would step in, and so on. After about ten minutes in, the Philadelphia Police Department came with an automated external defibrillator (AED). The police are trained on how to use AEDs and to provide emergency medical care. They took over for all the bystanders and the patient was shocked and taken to the hospital. We were sent on our way and told to continue running. It was a little weird!

CPHI: Let’s back up for a minute. You are a Master of Public Health (MPH) student, but clearly you are well trained in CPR. What is your background?

KS: It’s crazy because 40,000 people ran the Broad Street Run and for me to come upon this is just mind-blowing – really serendipitous. My background is in cardiac arrest research and education. By profession I spend my days learning as much as I can about CPR and ways to improve it, ways to disseminate it, and ways to make survival much better. To come across this situation where I needed to use it was crazy.

CPHI: Who were other bystanders?

KS: Most of the people that were helping the collapsed runner had medical backgrounds: nurses, a physician, and me. The most important take-home message is that he didn’t need a medical professional; he just needed someone to recognize that he was in cardiac arrest and that he needed CPR. Anyone who is trained can do that. If you’re not trained in CPR, you should be!

CPHI: How was it meeting the collapsed runner the next day in the hospital?

KS: I went to the hospital after he arrested and I was able to meet his family. They were very nice and very thankful. I’m happy to know that he will go back to having a normal life.

CPHI: I want to take a moment to address a common misconception: many people think a heart attack is the same as a cardiac arrest. Can you help clear up this confusion?

KS: A cardiac arrest is when your heart stops and blood flow stops to the entire body. With a heart attack, your heart doesn’t stop; rather, there is a blockage. Generally, people who have a heart attack have chest pain, they go to the hospital, and they can recover. Cardiac arrest generally happens with little to no warning and people are generally healthy when it happens. It can happen for a lot of different reasons and everyone’s reason is different.

CPHI: Is there a most common reason why cardiac arrest happens?

KS: There isn’t a most common reason – but there are situations that are most savable. The gentleman at the race had a savable arrest because he had a shockable arrest. This means that his heart was in a rhythm that a defibrillator could recognize and turn into a healthy heart rhythm. Places like airports, casinos, and races are places where lots of cardiac arrest victims do well – there are numerous educated people around and these places are heavily watched. But there are also places where people don’t do well – like low-income neighborhoods, which are less likely to receive bystander CPR.

CPHI: After you helped save a fellow racer, did you continue running?

KS: Yes, I finished the race!

For more information about CPR and cardiac arrest, please visit the Penn Medicine Center for Resuscitation Science website.

It was a pleasure to hear two inspirational people – Dr. Brian Work (MD, MPH) and Ms. Samantha Gross (JD, MPH) – talk about their paths to and work in community health at the Service Link, MedX, and Wharton Undergraduate Healthcare Club (WUHC) speaker event on Friday, April 10, 2015. My reflection can best be captured by the following lessons in career paths and working with community health.

Brian Work & Samantha Gross

On your journey to community health, remember:

Take advantage of serendipity

Nothing is irrevocable

Appreciate conversations / advice from people (even if unsolicited)

Participate in community work now! It’s called “practicing” medicine for a reason – it needs to become a habit. Life will already be full if you don’t prioritize community work now.

Community work embodies how medicine can improve with an interdisciplinary approach:

Community work makes Brian a better hospitalist

Community allows for engagement with a more diverse setting with more collaboration (e.g., medical-legal partnerships) instead of becoming too focused on a comfortable setting and subsequently isolated

Both medical treatments and legal policies are about harm reduction!

All of these insights and more were facilitated by our smooth moderator – Matthew Kearney – and packaged through Brian’s exuberant charm and Sam’s calm confidence. Look out for more at Service Link’s next speaker event (once per semester).

Written by: Neel Koyawala, Class of 2015 College of Arts and Sciences and the Wharton School at the University of Pennsylvania undergraduate student

Gala True, PhD is a medical anthropologist and folklorist whose research employs community engaged research approaches to improving access to and engagement in care. She has spent the past 5 years collaborating with U.S. Veterans of the wars in Iraq and Afghanistan on participatory action research to reduce barriers to care and improve post-deployment reintegration. She recently received funding from the Department of Veterans Affairs to build on that work through a photovoice project to engage Veterans with traumatic brain injury and their family members in efforts to improving patient-centered care in VA and community health settings.

Dr. Gala True’s work focuses on the use of visual and narrative methods in community engaged research, particularly with veterans of the wars in Iraq and Afghanistan. Her recent work has focused on understanding barriers to mental health care for veterans, and how we can address those barriers both within the VA and outside the VA. Using a community-based participatory approach, her work actively engages veterans and is very heavy on the advocacy side.

About the Work

CPHI: Tell us about how you got started working with veterans.

GT: I received my PhD in folklore from Penn, so from the very beginning of my training there was always an emphasis on the power of people being able to share their stories, and the importance of understanding how identity and community impact the way that people think about health, healing, and illness. From the moment I started at the VA about 8 years ago, I absolutely loved working with veterans. No matter how many times I think I’ve heard their stories, they’ll look at it from a different angle and say something powerful – I feel like I’m constantly learning.

“No matter how many times I think I’ve heard their stories, they’ll look at it from a different angle and say something powerful – I feel like I’m constantly learning.”

CPHI: How has this worked helped you describe public health challenges faced by veterans?

GT: The biggest public health concern comes from the fact that what a veteran is experiencing may be different from someone who didn’t serve, whether it’s a physical health problem, a mental health problem, or a work-related issue like transitioning back into the workforce. Health professionals and healthcare organizations need to be aware of what the special issues might be for veterans, and also what the resources are. There is an abundance of community and VA resources along with government funding and effort behind meeting the needs of veterans, but the issue is often about connecting veterans to these services.

CPHI: Describe your current research and advocacy projects.

GT: Currently, my work focuses on the use of visual and narrative methods in community-based research, particularly with veterans of the wars in Iraq and Afghanistan. I have done a life-story study with veterans who served in Iraq and Afghanistan to understand how they see trauma experiences during deployment to combat. The work focuses on how they see those traumas as fitting within the life-course of their entire life, and how they think about moving forward and recovering from those traumas. I have directed a photovoice project, using community based participatory research methods, with veterans who served in Iraq and Afghanistan, and it’s been going on for about 3 years now and has been very heavy on the advocacy side.

CPHI: Can you provide examples of the types of products that result from these projects?

GT: The first kind of products that came out of the project was this exhibit of veterans’ photo narratives that tell their stories of military service and homecoming and seeking care and moving forward with their lives after military service. The advocacy part has been that veterans in the project have remained very engaged in thinking about what could be done to improve post-deployment care for themselves, their veteran colleagues, and their community, and what could be done to support reintegration into their communities. We present together to healthcare providers and policymakers both within and outside VA, to advocate for the healthcare and reintegration needs of post 9-11 veterans.

Understanding Barriers to Care

CPHI: How have the stories helped understand barriers to healthcare among veterans?

GT: Veterans’ reflections on how their military service and experiences impact on their physical and mental health have led to a more nuanced understanding of the barriers they face to getting the healthcare they need– mental healthcare in particular—and how we can address those barriers both within the Department of Veterans Affairs (VA) and outside the VA. In a recent paper in Qualitative Health Research, we found that veterans talked about stigma as a barrier to care, but it was a much more complicated concept for them, and some of the stigma they were talking about was the stigma they encountered from health care professionals.

CPHI: Can you discuss the barriers to mental healthcare described in your recent paper?

GT: A few common themes have come up with in the paper we just published. Some of these themes include:

#1: Aspects of military culture and identity can deter health seeking

The military is a total institution where you go in with the purpose to break down your civilian identity and build you back up into the identity of the soldier, Marine, Airman, etc. Veterans are taught not to complain about physical ailments, and in fact to blast through any pain, and this can contribute to them being resistant to acknowledge mental health symptoms or distress. There is also this de-emphasis in the military on the needs of the individual, and an emphasis on stoicism and self-reliance, which gets solidified during deployment. Veterans who are deployed will often be so focused on survival and watching out for the person to their right and to their left that they’re not thinking about their own health. There’s a concept called ‘battlemind,’ which is like a state of mental toughness that’s instilled during military training, solidified during deployment, but also continues beyond coming home; it can really have an impact on how veterans view their symptoms or report them to others.

#2: Symptoms and coping strategies as barriers to care

A lot of veterans come up with short-term coping strategies for things like insomnia, anxiety, panic attacks, and depression through alcohol, drugs, and self-isolation – ‘I’m going to stay in my apartment and won’t go out, then I won’t have any bad encounters.’ Unfortunately, their symptoms and coping strategies can be impediments to getting mental healthcare. For example, sometimes someone will have an appointment, but he/she will wake up and will feel incapable of getting in the car or dealing with the stressors of driving, going in confined spaces, or going into a healthcare setting. Veterans are very self-aware that those are short-term solutions – they don’t think ‘oh this is great! – Rather, they don’t necessarily know how to get from the short-term coping mechanisms into treatment or into longer-term, more adaptive coping mechanisms.

“There’s a concept called ‘battlemind,’ which is like a state of mental toughness that’s instilled during military training, and that state of ‘battle mind’ is really solidified during deployment, but also continues beyond coming home. “

#3: Negative healthcare encounters may deter treatment

A lot of veterans have stories about going to seek help and coming up against bureaucratic issues in terms of scheduling an appointment, feeling judged by people within the healthcare system, and having what might be thought of as “anti-patient centered care experiences” – such as women being perceived as they couldn’t possibly have been in a combat situation. Veterans discussed being stereotyped during healthcare encounters where they would be very well-groomed and well-dressed externally, but internally they were falling apart; they would hear comments from healthcare providers such as “well, you can’t be doing that badly—you’re young and fit.” There is a tendency in mental health to assess grooming and eye contact as signs of whether or not someone is in distress. This doesn’t take into account that many veterans continue to carry themselves with a military bearing long after separation from the service, even if they are experiencing mental health issues.

CPHI: How is Sandra Bloom’s (2013) work on the concept of sanctuary trauma relevant to your findings?

GT: I first heard about Bloom’s concept of sanctuary trauma from a colleague, and it felt very relevant to the narratives we were hearing from veterans about negative healthcare encounters they experienced when seeking treatment for their post-traumatic stress. Essentially, the concept outlines what happens when someone who has experienced a trauma seeks help, and they have negative encounters with the people and institutions that are supposed to be helping them; it’s deeply re-traumatizing for many patients, and can deter them from seeking further care. For example, veterans described how traumatizing it could be to be asked questions about suicidal thoughts, symptoms of post-traumatic stress, and experiences of military sexual trauma or combat related traumas. While providers might see these questions as routine—and they are important questions to ask—veterans observed the damage that can happen if they aren’t asked in the right language and the right setting. It’s a great argument for the importance of patient-centered care.

Benefits and Relevance in the Field

CPHI: What are the benefits of this methodology for veterans?

GT: Photovoice is a really powerful way to get into topics such as stoicism, the ‘battle mindset’, and self-identity. Veterans are able to reflect on these topics, articulate them, and then share them with each other. Additionally, using the photos and photovoice method allows veterans to reflect in a way that survey-based studies haven’t necessarily been able to dig into. For this project, a really important part of photovoice was the idea of empowering veterans and enabling them to be collaborators in the research.

“For this project, a really important part of photovoice was the idea of empowering veterans and enabling them to be collaborators in the research.”

CPHI: How are these findings relevant to public health and healthcare practitioners?

GT: First, we provide military competency training to providers and use real stories to help illustrate the gap between what providers know about military culture, what veterans might have experienced during a deployment, and what resources are available for support. We focus some of our efforts on non-VA providers since about half of veterans who are coming home from these recent wars are seeing providers who are outside the VA.

The other part is to try to make the VA a more patient-centered place for these recent combat veterans. We’ve been doing that by presenting our findings nationally to VA healthcare providers, staff and leadership. Additionally, our photovoice exhibit travels to different VAs and this encourages dialogue between VA providers and staff with veterans about creating more veteran-centered care.

CPHI: What new/upcoming projects are you working on?

GT: We just received a 3-year award from the VA to continue this work with veterans who served in Iraq and Afghanistan, but with a focus on veterans who experience mild to moderate traumatic brain injury. These individuals make up a population that has a lot of unmet needs and photovoice will be an important means for them to access and describe their experience. The most exciting part of this new project is the inclusion of a care partner for each veteran, such as a family member, or close friend who’s most involved in supporting them in community reintegration. Their stories and experiences are just as important as the veterans’ but often go unheard.